Pure Pelvic Health New Patient Intake and Health History

Patient contact information

Please use this format 000-000-0000
Please use this format 000-000-0000
Emergency Contact
Please use this format 000-000-0000
Extended health insurance

Please let us know if you will be submitting your physiotherapy expense to extended health insurance

Extended Health Insurance(s): Please check all that apply
Current Pelvic Floor Symptoms?


Please let us know about the pelvic floor issue or symptom you are seeking treatment for


Do you currently have any of these symptoms of pelvic floor dysfunction?

Pelvic Floor Symptoms: (Please check all that apply)
Your answers help us understand any other pelvic floor issues, symptoms, or dysfunction that you may be experiencing.
Gynecological history if applicable
Are you currently pregnant?
Are you currently breastfeeding?
Do you get regular periods
Medical history
Please list any medications you are taking for THIS CONDITION. Medication name, dose, does it help?
Please list any other medications you are currently taking
Please check all that apply
Do you experience any of the following?
Family Doctor
I consent to sharing my Pure Pelvic Health initial assessment report with my family physician to facilitate continuation of care and the best possible treatment outcome *
Physician specialists for this condition
Specialist One
Specialist Two
I consent to sharing my Pure Pelvic Health initial assessment report with my physician specialist to facilitate continuation of care and the best possible treatment outcome
Complimentary healthcare providers for this condition
Complimentary Provider One
Complimentary Provider Two
I consent to sharing my Pure Pelvic Health initial assessment report with my complimentary healthcare providers continuation of care and the best possible treatment outcome
Central Sensitization Inventory

Central Sensitization Inventory:  Please check the best response for each statement

I feel tired and unrefreshed when I awake from sleeping *
I have anxiety attacks *
My muscles feel stiff and achy *
I grind or clench my teeth *
I have problems with diarrhea and / or constipation *
I need help performing my daily activities *
I am sensitive to bright lights *
I get tired very easily when I am physically active *
I feel pain all over my body *
I have headaches *
I feel discomfort in my bladder and / or burning when I urinate *
I do not sleep well *
I have difficulty concentrating *
I have skin problems such as dryness, itchiness or rashes *
Stress makes my physical symptoms worse *
I have low energy *
I have muscle tension in my neck and shoulders *
I have jaw pain *
Certain smells, such as perfumes, make me feel dizzy and nauseated *
I have to urinate frequently *
My legs feel uncomfortable and restless when I am trying to go to sleep *
I have difficulty remembering things *
I suffered trauma as a child *
I have pain in my pelvic area *
Electronic Communication

Canada's Anti-Spam Legislation (CASL) requires us to obtain your written consent before we send you any communications by email (or text). We may occasionally contact you to: 1. Request your feedback regarding the services you have received from Pure Pelvic Health 2. Provide you with an invoice, receipt, or other billing related information 3. Remind you of an appointment or provide information or special instructions regarding your appointment 4. Provide you with valuable health and rehabilitation information

My consent to receiving email and / or text communication from Pure Pelvic Health *
Cancellation Policy

Pure Pelvic Health requires 48 hours notice to cancel or reschedule an appointment. Patients cancelling or rescheduling appointments with less than 48 hours notice will be charge a fee equal to 50% of the scheduled service. Patients cancelling the day of their appointment or not showing up for their scheduled appointment will be charged a fee equal to 100% of the scheduled service. We understand that unexpected situations do arise and we will work with you to avoid late fees whenever possible. Please note that we have a long list of patients waiting for appointments and when you cancel without adequate notice it is more difficult for other patients to adjust their schedules to accommodate a last minute cancellation.

My acknowledgement of the Pure Pelvic Health cancellation policy *
Consent to assessment and treatment

Thank you for the confidence and commitment you are demonstrating through your decision to pursue pelvic health physiotherapy. Before we get started, we would like to review some information regarding the internal component of your assessment and treatment. There are three main reasons that we assess and treat the pelvic floor muscles internally, either rectally or vaginally. The first is that these muscles cannot be palpated or reached externally, The second is that we are unable to ensure that your prescribed exercises are being completed properly. Lastly, and most importantly, we are assessing to see whether these muscles are lengthened and weak, or tightened and weak. This determination will dictate the course of your treatment. If we look at the research, there is clear evidence to suggest that giving written or verbal cues for pelvic floor muscle training does not constitute adequate training. Additionally, there are guidelines that recommend that pelvic floor muscle training be completed using an internal approach or biofeedback. Like any course of treatment, on rare occasions patients can experience the following adverse reactions: NAUSEA OR LIGHTHEADEDNESS, PAIN OR DISCOMFORT, SKIN IRRITATION OR REACTION TO LUBRICANT GEL, ANXIETY OR EMOTIONAL DISTRESS, BLEEDING DURING OR AFTER TREATMENT UNRELATED TO MENSES. Please inform your physiotherapist should any of these reactions occur. We cannot perform internal treatment on patients under the following circumstances. If any of these apply to you, or if this information changes in the future, please inform your physiotherapist: ACTIVE INFECTION, RADIATION INJURY LESS THAN 12 WEEKS, POST-OPERATIVE LESS THAN 6 WEEKS (12 WEEKS FOR PROLAPSE REPAIR), ACTIVE RECTAL BLEEDING, SEED IMPLANTS OF RADIOACTIVE MATERIALS, IF YOU ARE PREGNANT AND HAVE BEEN ADVISED BY YOUR DOCTOR TO ABSTAIN FROM INTERCOURSE. Potential benefits of treatment may include: DECREASED SYMPTOMS, IMPROVED STRENGTH, AWARENESS AND FLEXIBILITY, IMPROVED BLADDER/BOWEL CONTROL, DECREASED PAIN AND DISCOMFORT, IMPROVED ABILITY TO PERFORM DAILY ACTIVITIES, IMPROVED KNOWLEDGE AB OUT MANAGING AND TREATING YOUR CONDITION. If I do not wish to undergo the internal assessment and treatment of my pelvic floor, I will discuss alternatives with my physiotherapist, family doctor or my specialist.

My consent to assessment and treatment *